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Complaint 0 of 0 in "Claim Denied or Delayed"

Insurance Carrier: Transamerica
State: Oregon

Consumer Complaint:

I was employed by Progressive Insurance when I took sick leave and then a leave of absence for a surgery. While on leave of absence my premiums were not deducted from my payroll. I was subsequently allowed to continue my life insurance policy as long as I continued to pay the premiums myself. I completed the forms for this continuation of coverage in August of 2005. The policy was initially effective 1/1/2004.

I filed a claim for benefits under the policy's "accelerated death benefit rider for critical care condition", which is a separate rider from the "terminal illness accelerated death benefit option" rider. The critical care condition rider allows for a benefit to be paid upon diagnosis of heart attack, stroke, cancer, renal failure, or major organ transplant surgery. I was diagnosed with cancer in-situ on 12/31/03 and diagnosed with cancer "that had properties to infiltrate and cause metastasis" (their words) on 02/23/04. I completed the form and was denied based on the definition of waiting period. Their denial letter stated: "Waiting Period means the 30-day period after the date of issue of this rider. You are eligible for benefits under this Rider if the Covered Insured is diagnosed for the first time, after the Waiting Period has expired." "This Rider was issued on February 1, 2004. You were diagnosed on February 19, 2004, which is during the 30-day elimination period. Based on the information received from Dr. *** and Dr. ***, your claim does not qualify for Critical Care Benefits." They then advised me of my rights to appeal, including that if my plan is an ERISA plan I can bring a civil action. So, I cannot determine if they are denying based on information from the doctors involved, or if they are denying based on the waiting period. It appears that the denial is based on the waiting period; however I cannot determine where they came up with the rider issue date of February 1, C92004. The policy was issued prior to that date and the rider was attached. Is there is an issue with me continuing coverage and paying the premiums myself? Thank you for your help in this matter. This is so important to me.

Insurance Expert Answer:

I'd like to be able to help but really can't as it would take a lot more review and research than we can do on this website. Further, if the policy was issued on 1/1/04 that's AFTER the initial diagnosis so you may be ineligible for the benefit.

In addition, I am concerned that the time to appeal under ERISA (if applicable) may have lapsed years ago. While I was VERY interested to learn that companies finally are using the "critical care condition" provision (one of the executives of FreeAdvice created the first critical illness rider ever issued in the US by adapting policies used in South Africa and fighting it thru the bureaucracy) this is beyond what we can do on this site. I'd suggest that you see a local lawyer and get some specific advice you can rely on.